Pharmacy communications with physician offices to clarify prescriptions

SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2017) 1e5

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RESEARCH

Pharmacy communications with physician offices to clarify prescriptions Marie Smith*, Bradley Sprecher a r t i c l e i n f o

a b s t r a c t

Article history: Received 25 August 2016 Accepted 19 December 2016

Objectives: Our study was conducted to: (1) characterize the type and extent of prescription clarification communications between community pharmacies and physician offices, (2) describe the interventions made by community pharmacists, and (3) determine the time frame to clarify prescriptions prior to dispensing. Design: A convenience sample and cross-sectional study. Setting: Five independent community pharmacies. Participants: Pharmacists and pharmacy technician staff members. Intervention: Participating pharmacy staff members documented the type of interventions and length of time to resolve prescription clarifications. Main outcome measures: Number, type, and reason for pharmacist interventions to clarify prescriptions. Results: Prescriptions that required clarification with physicians’ offices were mostly new (n ¼ 105; 74%) compared with refill prescriptions (n ¼ 36; 26%). Electronic prescriptions (n ¼ 51; 36%) required clarification more often than other types of prescription transmission. New prescriptions transmitted by e-prescribing required pharmacy-physician office communications 4-fold more frequently than faxed prescriptions and nearly 2fold more frequently than written prescriptions. The most frequent reasons for pharmacy communications with the physician office were prior authorization approval (n ¼ 45; 32%) and missing prescription information (n ¼ 22; 16%). The most frequent resolutions involved dispensing a different dosage strength (n ¼ 19; 11%) and different drug (n ¼ 17; 10%). At the end of the study period, 30 (17%) prescription clarification cases were unresolved; most of the unresolved cases involved prior authorizations. Person-to-person telephone contacts had an 80% resolution rate compared with a 55% resolution rate for fax communications (P <0.001). The time frame to clarify prescriptions ranged from 6 minutes to more than 14 days. Conclusion: Person-to-person telephone contacts may be more efficient than fax communications for resolving prescription clarifications, especially for more complex information needs. This study lends to ongoing improvement efforts in e-prescribing interfaces with pharmacy information systems to reduce the burden of prescription clarification. © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Prescription review by pharmacists before dispensing a medication is an important step and a “check and balance” method to prevent medication errors. It is estimated that Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Previous presentation: Some of the data in this study were presented at the American Pharmacists Association Annual Meeting, San Diego, CA, March 28, 2015. * Correspondence: Marie Smith, PharmD, Palmer Professor and Assistant Dean, University of Connecticut School of Pharmacy, 59 N. Eagleville Rd, Unit 3092, Storrs, CT 06269-3092. E-mail address: [email protected] (M. Smith).

outpatient preventable medication errors account for approximately 3.3 million outpatient visits annually,1 and outpatient adverse drug events may cost as much as an estimated $8 billion per year.2 Prescription problems have been reported for both administrative and clinical reasons. Some administrative reasons have included problems with prior authorization approvals (37%), formulary issues (26%), and lack of clarity about refill status (11%).3 Some clinical reasons have been reported as clarifications for dosage issues (5%-21%), patient instructions (8%-10%), and allergies or harmful drug interactions (4%-11%).1,3,4

http://dx.doi.org/10.1016/j.japh.2016.12.072 1544-3191/© 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

SCIENCE AND PRACTICE M. Smith, B. Sprecher / Journal of the American Pharmacists Association xxx (2017) 1e5

Key Points Background:  The transmission of prescriptions from a physician office to pharmacies has changed from handwritten prescriptions that were brought to the pharmacy by the patient to nearly 75% of all prescriptions being transmitted electronically.  Studies have found that the introduction of e-prescribing has resulted in missing or conflicting prescription information that required further physician office communications. Findings:  New prescriptions transmitted by e-prescribing required pharmacyephysician office communications 4-fold more frequently than faxed prescriptions and nearly 2-fold more frequently than written prescriptions did.  Person-to-person telephone contacts had an 80% resolution rate compared with a 55% resolution rate for fax communications.

Mail-order pharmacies reported that the most frequent type of prescription issues that required clarification with the prescriber included unclear or missing directions or refill quantities (24%), unclear dosage (20%), unclear drug name or strength (13%), and missing administrative data (1%-6%).5 One study in primary care physicians’ offices reported that the most frequent contributing factor (41%) to medication errors and adverse events was due to written and verbal communication problems between the physician offices and pharmacists. The most frequent written communication problems were wrong doses and wrong drugs, whereas the most frequent verbal communication issues were misunderstood verbal physician orders and miscommunications between nurses and pharmacists regarding the correct medication or dosage.6 The introduction of e-prescribing was expected to improve the quality of prescription information transmitted between prescribers and pharmacists. However, a study conducted in 2006, when e-prescribing was being introduced, found that there were several problems requiring a pharmacist intervention with e-prescriptions, such as omitted prescription information (33%), dosage problems (8%-10%), and drug interactions or allergies (2%-3.5%).7 Another study reported that pharmacists frequently encountered missing or conflicting information, such as patient instructions or quantity to dispense on electronic prescriptions. These findings contribute to the unrealized potential of electronic prescribing systems to generate a prescription that did not necessitate clarification with the prescriber.8 The Surescripts 2015 National Progress Report states that 75% of all prescriptions are transmitted electronically.9 In 2013, Surescripts reported that 96% of internists and 85% of family physicians had adopted e-prescribing.10 However, e-prescriptions sometimes contain incomplete or

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ambiguous information that requires clarification with the prescriber before completion of the pharmacy dispensing processes.11 One of the proposed advantages of e-prescribing systems was the improved prescription information transmission from the physician office to pharmacies and the assumption that there would be fewer pharmacy callbacks to a physician’s office.12,13 However, pharmacist-physician communications have not been well studied since e-prescribing systems have been implemented in most physician offices and pharmacies. Objectives Our study was conducted in 5 independent community pharmacies with e-prescribing capabilities to: (1) characterize the type and extent of prescription clarification communications between community pharmacies and physician offices, (2) describe the interventions made by community pharmacists as a result of physician office communications, and (3) determine the time frame to clarify prescriptions prior to dispensing. Methods This cross-sectional study was conducted in 5 independent community pharmacies in Connecticut. The prescription volume in these pharmacies ranged from 600 to 2500 per week, and all pharmacies were in a suburban or urban location. The pharmacy owner or manager at each pharmacy was contacted about the study objectives and requirements as a study site. Study personnel met with each pharmacy owner or manager to observe the pharmacy’s prescription processing workflow and to review existing communication policies with physician offices. The pharmacy owners or managers had input into the development of a standardized data collection instrument. The standardized instrument collected information about the prescription type, communication initiator and method, number and type of people involved at the pharmacy and physician office, reason for communication, resolution of the problem, number of contacts required, and time frame to resolve the problem. The data collection form was designed so that information was collected using check boxes and lists such that pharmacy staff members could complete them in an efficient manner. All pharmacy staff personnel (pharmacists and pharmacy technicians) volunteered to participate, and they were trained on the use of the data collection form with some example scenarios. Printed pads of the data collection forms were delivered to each pharmacy. The pharmacy staff members in each pharmacy determined the best locations to place the data collection forms (usually near a telephone or fax machine) so that the form would be readily available in the prescription processing workflow to record information. Pharmacy staff members were instructed to complete the form whenever they contacted a physician office or received a communication from a physician office regarding a new or refill prescription that required clarification. If a data collection form was initiated yet not completed (i.e., awaiting a response from the physician office), the form was flagged and kept in a

SCIENCE AND PRACTICE Pharmacy-physician office communications

Descriptive statistics were computed for all variables. Pearson c2 tests were used for nominal data, such as differences in the communication types for resolving prescription clarifications and types of unresolved clarifications. The Fisher exact t test was used for the analysis of mean time to resolve prescription clarifications. The a priori level of statistical significance was P <0.05.

communications, which is 4-fold more frequent than faxed prescriptions and nearly 2-fold more frequent than written prescriptions. For refill prescriptions, those prescriptions transmitted by fax (25%) and telephone (25%) generated the need for physician office communications more often than those sent by e-prescribing (17%). The most frequent methods of pharmacyephysician office communication were person-to-person telephone calls (50%) and fax (38%). Most communications were initiated by a pharmacist (66%); our study found that 58% of prescription clarifications involved communications with medical assistants or clerical office staff members, whereas 24% of the communications involved prescribers and 18% involved nurses. Nearly 61% of the prescription communications were resolved with a single pharmacy contact, and an additional 26% were resolved with 2 pharmacy contacts. However, 13% of the prescription communications required 3 or more pharmacy contacts to achieve a resolution. The most frequent reasons (Table 2) for pharmacy communications with the physician office were prior authorization approval (32%), missing prescription information (16%), clarification of prescription information (10%), and excessive or insufficient dose or duration (10%).

Results

Resolution of problems

Pharmacy volume

The most frequent resolutions (Table 3) involved dispensing a different dose strength (11%) and different drug (10%). At the end of the study period, 17% of prescription clarification cases were unresolved. Most of the unresolved cases involved prior authorizations (92%) compared with other reasons for unresolved cases (8%; P <0.05). Person-to-person telephone contacts had an 80% resolution rate compared with a 55% resolution rate for fax communications (P <0.001).

folder so that a pharmacy staff member could complete the form if the resolution occurred on a different shift. Study personnel were available to the pharmacy staff members for any questions regarding the data collection process, and they visited each pharmacy at least twice during the data collection period. Data were collected over a 14-day period during late January 2014. To capture resolution of prescription clarifications that were unresolved at the end of the 14-day study period, an allowance of an additional 3 days was used. The completed forms were picked up at each pharmacy and then collated for data analysis. The University of Connecticut Institutional Review Board approved the study. Data Analysis

Two pharmacies were categorized as low volume (600 prescriptions/week), 1 pharmacy was intermediate volume (approximately 1200 prescriptions/week), and 2 pharmacies were high volume (>2500 prescriptions/week). Tests comparing the number of contact attempts, initial contact method (e.g., electronic, face-to-face, voicemail), and time-toresolution failed to find any statistical differences between stores by prescription volume. Prescription communications One hundred forty-one prescriptions that required clarifications by the pharmacy were recorded during the study period (Table 1). New prescriptions accounted for 74% of the communications with physician offices, whereas refill prescriptions accounted for 26% of those that required communications. When combining the data for new and refill prescriptions, the transmission method that most often required clarification was e-prescription (36%). Table 1 indicates that 43% of new prescriptions transmitted by e-prescribing required pharmacyephysician office

E-prescribing Handwritten Fax Telephone Voice mail message Typewritten Unspecified Total

The time frame involved to resolve the identified prescription problems ranged from 6 minutes to more than 14 days. When 3 or more people were involved in the pharmacyphysician office communications, time to resolution was more than 20 minutes (P <0.05), and it was longer than for only 1 or 2 participants (P ¼ 0.038). Approximately 70% of the calls requiring more than 20 minutes to resolve the problem were initiated by a pharmacist because of the complexity of the required clarification. Sixteen communications were initiated by physician office staff members to clarify the need for prior authorizations. Of Table 2 Reasons for physician office contact by pharmacy staff personnel

Table 1 Type of prescription transmission requiring further clarification Prescription transmission type

Resolution time frame involved

Reasons for physician office contact (N ¼ 141)

New Rx n (%)

Refill Rx n (%)

Total n (%)

45 (42.9) 24 (22.9) 10 (9.5) 8 (7.6) 1 (1.0) 2 (1.9) 15 (14.3) 105

6 (16.7) 1 (2.8) 9 (25.0) 9 (25.0) 0 2 (5.6) 9 (25.0) 36

51 (36.2) 25 (17.7) 19 (13.5) 17 (12.1) 1 (0.7) 4 (2.8) 24 (17.0) 141

Prior authorization Missing prescription information Clarification of prescription information Excessive or insufficient dose or duration Nonformulary drug Verification of medication list and fill history Product, drug, or strength not available Drug interaction, allergy, or side effect Possible fraud, abuse

n (%) 45 22 14 14 13 13

(31.9) (15.6) (9.9) (9.9) (9.2) (9.2)

12 (8.5) 4 (2.8) 4 (2.8)

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SCIENCE AND PRACTICE M. Smith, B. Sprecher / Journal of the American Pharmacists Association xxx (2017) 1e5

Table 3 Resolutions of prescription clarificationsa Resolutions (N ¼ 172 ) Dispensed with different: Strength Drug Frequency Dose Quantity Dosage form Unresolved Dispensed as written or no change Added missing information Verified patient information Prescription was not filled Patient education or counseling Prescriber drug product information Told patient to contact physician Other a

n (%) 59 19 17 7 6 6 4 30 16 12 12 9 4 3 1 26

(34.3) (11.0) (9.9) (4.1) (3.5) (3.5) (2.3) (17.4) (9.3) (7.0) (7.0) (5.2) (2.3) (1.7) (0.6) (15.1)

Prescriptions could have multiple types of resolutions.

these physician officeegenerated calls, resolution times were greater than 20 minutes compared with pharmacist-initiated calls (P ¼ 0.033). Discussion Despite the promise of e-prescribing to reduce the need for prescription communications and callbacks from the pharmacy to physician offices, there is evidence that prescription clarifications continue to occur. Our study showed that physician office contacts for new prescriptions transmitted by e-prescribing software occurred nearly twice as often as those for written prescriptions and 4-fold more often than for fax prescriptions. Even with the high adoption rates of e-prescribing and the evolution of e-prescribing software, there are challenges with interoperability with pharmacy information systems. Implementation of interoperability standards may help to mitigate issues frequently encountered for electronically generated prescriptions. Odukoya and Chui14 identified several e-prescribing design weaknesses that contribute to the need for pharmacy communications with physician offices. These weaknesses were often due to incomplete information sent electronically to process a prescription. One common design challenge is the mismatch in textbox size in the e-prescribing and pharmacy systems. The mismatch resulted in pharmacy staff members not being able to see necessary information, such as drug names (e.g., long drug names, combination drugs) or prescription instructions. Our study showed that nearly 16% of the physician office communications were for missing information. Other e-prescribing software design challenges involved the mismatch in drug quantities and inability to discontinue old prescriptions, which accounted for 18% of the reasons for physician office communications in our study. Warholak and Rupp7 found the most common reason for pharmacist interventions on e-prescriptions was to supplement omitted information (31.9%), especially missing directions. Dosing errors were also common (17.7%). Our study found that these 2 reasons accounted for 26% of communications with physician offices for all types of prescriptions. Our findings were consistent with the results of a study,7 as most cases were resolved and dispensed with a modification 4

of the drug, dose strength, or frequency; we reported that 17% of the prescription communications were unresolved and could not be dispensed. Most of these cases related to prior authorizations. Unfortunately, other studies did not record this element as a reason for physician office communications. Our study found that person-to-person telephone contacts had a significantly higher resolution rate compared with the resolution rate for fax communications. Sending a fax may be easier and quicker to initiate, but person-toperson communication has a higher resolution rate and can improve the efficiency in resolving prescription clarifications with physician office communications. Fax communications are still a common method of communication between the pharmacy and physician offices, yet they do not appear to be as efficient to resolve prescription clarifications, especially for more complex issues beyond missing information. Our study recorded the time frame to clarify the prescription, which ranged from 6 minutes for missing information to more than 14 days for more complex issues involving prior authorizations or cases in which there was no response. Another study7 calculated the cost of pharmacist time to resolve the problem, while we were more concerned with the length of time and number of contacts required to resolve the issue. We found that 13% of the prescription communications required 3 or more pharmacy contacts to achieve a resolution. This finding demonstrates the workflow impact and delayed time for the patient to receive the prescription because of the need for clarifications with the prescriber’s office. Our study found that 24% of the communications involved prescribers and 18% involved nurses. Another study found that only 13% of primary care physicians were contacted by a pharmacist regarding new prescriptions, and 79% of physicians reported that a nurse had the most contact with pharmacists. 15 In our study, we believe that the physician office workflow processes involve office clerical staff members or medical assistants as the first point of contact for pharmacy calls, and messages are then forwarded to prescribers or nurses to address the clarification. In addition, clarifications initiated by physician office personnel take longer to resolve than those initiated by pharmacists or technicians, which may reflect a greater familiarity of the prescription fulfillment process by pharmacy staff members. Finally, our study findings are relevant to ongoing improvements in e-prescribing software interfaces to minimize the need for clarifications with prescribers’ offices. We encourage e-prescribing vendors to test new or changed e-prescribing features or interfaces with pharmacy information systems to assess how changes can affect the need for e-prescription communications with the prescribers’ offices.

Limitations Certain aspects of the study design limit its external validity, such as the small number of pharmacies, 14-day study period, and narrow geographic distribution. The sampling method also relied on the volunteer nature of the data collection by pharmacy staff personnel, and it is likely that this led to underreporting of prescriptions that required pharmacy clarifications. There were instances in which data

SCIENCE AND PRACTICE Pharmacy-physician office communications

were unspecified or categorized as “other,” which could have skewed our findings. In addition, the authors were not present during data collection and were not able to verify independently whether data were collected consistently throughout the study period. We believe that pharmacy staff personnel had different interpretations about classifying a prescription renewal request as a refill request; future data collection instruments should include a separate category for prescription renewals. Heterogeneity between pharmacies regarding such variables as prescription volume, staffing levels, and staff responsibilities yields insights into communication patterns for individual stores yet limits the statistical power for some data analysis and the generalizability of study findings. Conclusion Whereas e-prescribing can potentially improve the safety and effectiveness of patient care, it has not eliminated the need for pharmacyephysician office communications to clarify missing information, prior authorization approvals, or inappropriate prescription data. Person-to-person telephone contacts resolved a higher rate of prescription clarifications than fax communications did, especially for more complex information needs. The length of time to resolve prescription clarifications can vary widely with the complexity of information requested. A delay in timely communications because of prescription clarifications can interrupt the pharmacy workflow, as the prescription cannot be dispensed. Pharmacy staff personnel may find it useful to know the preferred communication methods for different physician offices so that patients are not inconvenienced by delays in communications to clarify prescriptions. Acknowledgments The authors thank Katelyn O’Brien, PharmD, and Christina Kazazian, PharmD, for their contribution to the data collection process in this study.

References 1. National Priorities Partnership. Preventing mediation errors: a $21 Billion opportunity; 2010. Available at https://www.qualityforum.org/NPP/docs/ Preventing_Medication_Error_CAB.aspx. Accessed August 2, 2016. 2. Burton MM, Hope C, Murray MD, Hui S, Overhage JM. The cost of adverse drug events in ambulatory care. AMIA Annu Symp Proc. 2007:90e93. 3. Hansen LB, Fernald D, Araya-Guerra R, Westfall JM, West D, Pace W. Pharmacy clarification of prescriptions ordered in primary care: a report from the Applied Strategies for Improving Patient Safety Collaborative. J Am Board Fam Med. 2006;19(1):24e30. 4. Chen Y, Neil KE, Avery AJ, Dewey ME, Johnson C. Prescribing errors and other problems reported by community pharmacists. Ther Clinical Risk Manag. 2005;1(4):333e342. 5. Fiefer RA, Nevins LM, McGuigan KA, Paul L, Lee J. Mail-order prescriptions requiring clarification contact with the prescriber; prevalence, reasons, and implications. J Managed Care Pharm. 2003;9(4):346e352. 6. Hickner J, Zafar A, Kuo GM, et al. Field test results of a new ambulatory care medication error and adverse drug event reporting systeme MEADERS. Ann Fam Med. 2010;8(6):517e525. 7. Warholak TL, Rupp MT. Analysis of community chain pharmacists’ interventions on electronic prescriptions. J Am Pharm Assoc. 2009;49(1):59e64. 8. Nanji KC, Rothschild JM, Boehne JJ, et al. Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy. J Am Med Inform Assoc. 2014;21(3):481e486. 9. Surescripts. 2015 National Progress Report. Available at: http:// surescripts.com/news-center/national-progress-report-2015. Accessed October 31, 2016. 10. Surescripts. 2013 National Progress Report and Safe-Rx Rankings. Available at: http://surescripts.com/docs/default-source/national-progressreports/surescripts_2013_national_progress_report.pdf. Accessed October 31, 2016. 11. Palchuk MB, Fang EA, Cygielnik JM, et al. An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies. J Am Med Inform Assoc. 2010;17(4):472e476. 12. Rupp MT, Warholak TL. Evaluation of e-prescribing in chain community pharmacy: best-practice recommendations. J Am Pharm Assoc (2003). 2008;48(3):64e70.  C. Perceptions of e-prescribing efficiencies and 13. Lapane KL, Rosen RK, Dube inefficiencies in ambulatory care. Int J Med Inform. 2011;80(1):39e46. 14. Odukoya O, Chui MA. Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing. J Am Med Inform Assoc. 2012;19(6):1059e1065. 15. Rannelli PL, Biss J. Physicians’ perceptions of communication with and responsibilities of pharmacists. J Am Pharm Assoc (Wash). 2000;40(5):625e630. Marie Smith, PharmD, Professor of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT Bradley Sprecher, PharmD, P4 pharmacy student at the time of this study, Western Mass Compounding Center, West Springfield, MA

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